| CARE
PLANS: FORMS, EMERGENCY, TRANSITION SUMMARIES |
|
|
| Care Planning Forms |
The Center for Children with Special Needs at Seattle Children's has developed a Care Notebook and other care planning forms including three simple, straight forward care planning forms that can help teens share important information in consistent ways. This could help them to begin to think about managing their own care. These tools were created together with teen consultants who have chronic conditions. The forms are:
- Getting to Know Me
- What's the Plan?
- In Case of Emergency
|
http://cshcn.org/planning-record-keeping |
| Care plan: Comprehensive,
Youth focused |
Transition ComPlan
Shriners Hospital for Children – Boston BurnsTransition
care plan is designed to facilitate specific transition
planning for 14-15 , 16-17, and 18-19 year old youth as
they prepare to transition from Shriners Hospitals system
of care. Specific domains include school, post- secondary
education plans, health care and health care funding. |
Transition COMPlan
[word]
[pdf] |
| Care Plan: Comprehensive,
Youth Focused |
Transition Care Plans: 14-20, 14-17
and 18-21 years
Shriners Hospital for Children - LexingtonThe Boston Tool
was expanded and adapted by the Lexington Hospital to
reflect the potential needs of younger and older adolescents.
These two care plans are facilitate transition planning
for early/mid teen years and later teen years. Topics
include plans for health condition management, health
insurance, functional independence, school to work, independent
living, and community inclusion. |
Transition Care Plan
14-21
[pdf]
Transition Care Plan
14-17
[pdf]
Transition Care Plan
18-20
[pdf]
|
| Care Plan: Action—Youth
Focused |
Transition Action Care Plan
This care plan was modified by Shriners Hospitals from
the Medical Home Learning Collaborative Action Plan to
include areas of transition planning. Care coordinators
within Shriners find that this plan is very user friendly
and often is the only transition plan of care needed. |
Transition Action Care
Plan
[word]
[pdf] |
| Emergency Care Plans |
American Academy of Pediatrics
Emergency information for Children with Special Needs
This from provides information to emergency providers
regarding the child’s current providers, diagnoses
with base-line findings, current medications and allergies,
immunization status and common presenting problems/findings
with specific suggested management strategies.
The AAP has developed guidelines, forms and a policy statement
on emergency preparedness for CSHCN
Specialized Emergency Information Hitchcock Clinic-ConcordThis
form provides emergency physicians with common presenting
problems/findings with specific suggested management strategies. |
aap.org/advocacy/
blankform.pdf
aappolicy.aappub
lications.org/cgi/
content/full/pediatrics;
104/4/e53
www.medical
homeinfo.org/
tools/emer_med.html |
| HRTW Portable Medical Summary |
HRTW 1-Page PORTABLE MEDICAL SUMMARY
Excellent example of a one page health summary that can
be carried by youth and families for emergencies or routine
medical visits. |
- sample - medically complex [word]
[pdf]
- template - cognitive impaired [word] [pdf]
- template - portable medical summary [word] [pdf]
|
| Portable Medical Summaries |
National Center for Medical Home
Initiatives
Variety of medical summaries are sometimes titled care
plans on the Medical Home website. |
www.medical
homeinfo.org/
tools/assess.html |
| Transition Summary |
Adult Metabolic Transition Project
Non-Disorder Specific Medical Care: Clinical Treatment
Summary
One-page summary of service and independence |
depts.washington.edu/
transmet/The%20
process/summary.htm |
Transition Summary
Shriners Hospital for Children - This two page summary
is designed to provide youth with a succinct summary of
their care at SHC, current health status, including a
comprehensive listing of involved health care providers
by diagnosis, current medications, therapies, equipment
and supply needs functional capabilities, and future plans
.This summary should help adult health care providers
quickly focus on the youth’s comprehensive needs
including their transition needs/ plans. |
Transition Summary
[word]
[pdf] |
Audit Form for Pediatric to Adult
Services Transfer
British hospital transfer form |
hctransitions.ichp.
ufl.edu/resources.html |
